BALTIMORE COUNTY PUBLIC SCHOOLS STANDARD STUDENT ACCIDENT REPORT FORM

BALTIMORE COUNTY PUBLIC SCHOOLS STANDARD STUDENT ACCIDENT REPORT FORM

1. Name:

Home Address:

2. School:

Sex: M F Non-binary

Age:

Grade:

3. Time accident occurred:

A.M. P.M. Date:

Date accident reported:

Today's Date:

4. Place of accident:

School building School grounds To or from school School sponsored activity

5. NATURE OF INJURY Abrasion/Cut Amputation Bruise

DESCRIPTION OF THE ACCIDENT How did the accident happen? What was student doing? Where was student? Please describe the physical surroundings and conditions of the site of the event.

Burn Concussion

BCPS REPRESENTATIVE'S STATEMENT:

Fracture/Sprain

Other (Specify)

PART OF BODY INJURED Ankle/Foot Arm/Shoulder Elbow Eye Face Hand/Finger Head Other (specify)

Knee Leg Mouth Nose Torso Wrist

INJURED PERSON'S STATEMENT:

BCPS PROPERTY DAMAGE

No

Yes

WERE THERE ANY WITNESSES WITNESS NAME(s)/NUMBER(s):

No

Yes

6. BCPS individual in charge when accident occurred:

Present at the scene of accident:

No Yes

7. ACTION TAKEN

First aid treatment

By Name:

Sent home

By Name:

Sent for medical treatment By Name:

Name of Provider/Facility:

Other

(specify)

8. Was a parent or other individual notified?

No Yes When:

How:

Name of individual notified:

By whom?

9. LOCATION ? Mark the appropriate box and use the space to provide details (e.g. math hallway, room 213, soccer field, etc.)

Athletic field/Stadium

Parking Lot

Auditorium/Cafeteria

Restroom

Classroom

School Grounds

Corridor

Stairs

Dressing/Locker Room

Gymnasium

Other

Name of BCPS Representative Completing the form:

Contact Phone Number:

COPY DISTRIBUTION 1. Copy for Administrator 2. Copy to Nurse 3. Copy to Employee Absence and Risk Management (OEARM) Greenwood Office or ORM@

Revised 10-2019

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